Institutional Training Opportunities for PhD Students in Laboratory Medicine: An Unmet Career Development Need?

Abstract

In the United States, the credentialing of PhD-scientists as medical directors of clinical laboratories is driven by formal postdoctoral training programs. Prior to acceptance in one these accredited fellowships, however, a trainee’s exposure to the field can be far less standardized, with significant ramifications for their awareness and competitiveness. In the current article, we describe our recent experiences in developing local, institution-based immersion opportunities for PhD experiences in the subdisciplines of laboratory medicine (clinical microbiology, clinical chemistry, and molecular genetics/genomics). It is our hope that this article—and a corresponding online survey—can prompt reflection and discussion on the status of early career training opportunities in these key clinical areas.

laboratory medicine, clinical pathology, career development, medical director, PhD/graduate training, mentorship

Among clinical specialties in the United States, the discipline of laboratory medicine/clinical pathology is unique in that attending-level practitioners (medical directors of diagnostic laboratories) consist of both MD-trained physicians boarded by the American Board of Pathology (1, 2,), along with PhD-trained scientists boarded by subdiscipline-specific bodies (3, 4,). The latter groups include the American Board of Medical Microbiology (5,), the American Board of Medical Genetics and Genomics (6,), and the American Board of Clinical Chemistry (7,). Within each field, the MD- and PhD-pathways are defined by their own accredited fellowship programs and national examinations. Such credentialing, in turn, is required for an individual to serve as the medical director of a high-complexity diagnostic laboratory in the United States, according to the Clinical Laboratory Improvement Amendments and state licensure requirements (3, 8).

While the routine duties of MD- and PhD-trained laboratory directors ultimately converge, the stepwise pathway of career-development for each track differs significantly. For MDs, this sequence is well conserved—undergraduate education with premedical requirements, medical school (or MD-PhD program) by common application, ACGME-accredited residency by national match (Clinical Pathology or combined Anatomic/Clinical Pathology), and subspecialty fellowship—often with established institutional mentoring to guide trainees to the next respective step (1, 9,). In contrast, the pathways and associated timelines for PhD-scientists can be far more variable. The aforementioned fellowship programs serve as de facto ‘gatekeepers’ for the professions, at least for individuals who were not already established as medical directors outside the United States, with an earned doctorate in a relevant subject as the main prerequisite (3, 4). By their very nature, though, the personalized focus of PhD-studies differs considerably between institutions and individuals. Moreover, whereas some candidates apply for clinical fellowships near the end of graduate school (a direct progression), others may first pursue additional postdoctoral training or employment.

Even more so, the formative experiences that initially draw PhD applicants to clinical fellowships can vary significantly from person to person. Not uncommonly, interest is first sparked in the context of a research project related to diagnostic testing and/or clinical laboratory collaboration. This connection may then facilitate downstream opportunities for ad hoc mentorship and exposure (e.g., arrangements with a laboratory medicine faculty to participate in additional clinical laboratory activities). Alternatively, some fellowship applicants are already familiar with the diagnostic environment prior to graduate school, from predoctoral employment as medical technologists or technicians. With these and other backgrounds, the training narratives of clinical laboratory directors can be rich and varied, perhaps not surprising given the breadth of the laboratory medicine field and the diverse responsibilities of its practitioners (10).

At the same time, these varied professional inroads are also nonstandardized, potentially creating disparities of awareness and opportunity among young trainees who might otherwise be drawn to the field. While scientists who have navigated doctoral programs are certainty familiar with “traditional” academic careers in research and/or teaching, along with options in industry, their exposure to the clinical milieu is (at best) inconsistent. Graduate curricula typically omit coursework in laboratory medicine, and for those students who train at institutions not affiliated with local medical centers, even the possibility of individualized clinical mentorship is challenging. There have been occasional (and notable) exceptions to this status quo, for instance dedicated clinical chemistry doctoral programs at Cleveland State University and the University of Windsor (in Canada—no longer active, to our knowledge), which over several decades have successfully trained a number of current practitioners of this particular subdiscipline (11). By in large, though, many students undoubtedly complete their PhDs in the health-related sciences without a basic understanding of clinical laboratory careers. Awareness, moreover, does not necessarily ensure equitable access, given the competitive nature of fellowship programs and the potential advantage to applicants whose pre-fellowship circumstances happen to include clinical exposure.

In this context, nonuniversity-based forums are occasionally organized for PhD-scientists that provide educational opportunities in laboratory medicine. Various academic conferences, for instance, include career-development sessions for graduate students and research fellows, allowing them to network with established practitioners and gain insight about the field. Professional societies have likewise established programs for connecting mentors/mentees nationally and fostering longitudinal relationships, including the American Association for Clinical Chemistry (12,) and the American Society for Microbiology (13). While such experiences are highly valuable, they may fail to reach audiences not already aware of such careers, nor offer the same immersion as opportunities championed by a trainee’s home institution.

To address this potential gap, the Biomedical Research, Education, and Training Office of Career Development in the Vanderbilt University School of Medicine has for several years sponsored a training “module” in laboratory medicine, in conjunction with faculty who serve as medical directors in the Vanderbilt University Medical Center (VUMC) Diagnostic Laboratories. The module is 1 of 11 offered by their ASPIRE program, developed through a “Broadening Experiences in Scientific Training” (BEST) award from the National Institutes of Health (DP7OD018423) (14). The goal of the Vanderbilt ASPIRE program is to empower biomedical sciences PhD students and postdoctoral scholars to make well-informed career decisions, broadening their training experiences to facilitate efficient transitions to careers in nonacademic and academic venues. ASPIRE modules are short, noncredit-bearing electives for mid-/late-stage graduate students and postdoctoral fellows who fall outside of traditional coursework or lecture-based didactics.

The module in laboratory medicine has provided trainees with a personalized focus on either microbiology, chemistry, or genetics/genomics; they spend several hours per week for 1–2 months participating in the responsibilities of that service. This schedule is minimally disruptive to the trainee’s regular commitments, so research advisors have been supportive of the approach. Participants work alongside a clinical laboratory medical director, current fellow, and rotating pathology residents in activities that may include: (a) bench rounds within the clinical laboratory; (b) research-and-development meetings that focus on assay implementation; and (c) sessions of the Diagnostic Management Team, a VUMC practice in which each laboratory service convenes daily to systematically review challenging cases, address emergent questions (externally from physicians or internally from staff), and offer interpretive commentary posted to the electronic health record (15). Within these Socratic settings, participants are exposed to the overarching duties of laboratory medical directors, the subtleties of clinical problem solving, as well as other professional themes that often go unaddressed during graduate training (e.g., quality assurance, personnel, and infrastructure management, regulatory and financial requirements, and patient confidentiality/privacy). Overall, the goal of the experience is not to impart technical knowledge per se, but rather to provide an opportunity for trainees to gain an up-close appreciation of the field, while highlighting differences between research and clinical science. At the module’s conclusion, we hope that participants understand the role of clinical laboratorians as healthcare practitioners, including their interactions with other caregivers. For participants who are so inclined, the module can serve as a springboard to extended activities within that laboratory section (i.e., beyond the 2 months), arranged individually with the respective medical director.

The laboratory medicine module is advertised (via email and website) to all biomedical PhD students and postdocs at Vanderbilt (∼1000). A total of 22 individuals have enrolled in our program over the past 4 years, selected from 46 applicants. At the end of the module, each participant is sent a brief survey. Over 4 years, 100% of survey respondents strongly agreed that they learned new information in the module and 100% would recommend the program to their colleagues. We remain encouraged by this formal feedback, along with the fact that several participants have opted for a career in laboratory medicine (including 3 who have since completed their PhD training and achieved accredited fellowship positions at outside institutions, and a fourth who will soon be starting). Conversely, other participants have chosen not to pursue this career path; indeed, facilitating such informed decisions is also an important objective of the module.

More broadly, our efforts with the program have led us to reflect upon the general mechanisms of clinical career development for PhDs, including whether the national status quo for pre-fellowship exposure could be improved. Should more PhD programs in the United States incorporate formal experiences in laboratory medicine? Would such opportunities benefit the general quality of doctoral training, along with the career prospects of individual trainees? We believe that our local experiences at Vanderbilt highlight the upside of such exposure, while promoting synergy between the institution’s clinical, research, and educational missions. However, we remain curious as to the perspectives of other colleagues on the value of such programs, including any similar activities undertaken elsewhere. Pre-fellowship training in laboratory medicine could assume many forms, with our ‘module’ system as one of various possibilities (other examples might include structured coursework—conceivably even at the undergraduate level—or dedicated/intensive internship-periods within graduate studies).

Likewise, we acknowledge that large-scale implementation of such training could raise different challenges altogether. One consideration involves the dynamics of supply and demand: that is, whether these programs (enacted broadly) might generate more enthusiasm among trainees than is supported by the limited availability and competitiveness of fellowship positions. There are also important logistical constraints for the faculty who would oversee any local initiatives. Competing demands for time are a universal limitation in academic medicine, and any new curricula would require approval and support from institutional leaders. For example, we are fortunate at the Vanderbilt University School of Medicine that laboratory medicine is administered under the same academic department as multiple PhD programs (the Department of Pathology, Microbiology, and Immunology), removing potential barriers in this regard. But our arrangement is far from universal, and one could certainly envision administrative challenges if the department sponsoring an activity is unaffiliated with the trainees benefiting from it.

With these diverse considerations, the current reflection is being written in large part with the hopes of prompting further discussion within the professional community. To these ends, we have created a brief online survey via REDCap (The survey may be accessed at: https://redcap.vanderbilt.edu/surveys/index.php?s=R8FJ9ELDX9) (16), whose intended audience is current medical directors (or locally commensurate positions) of credentialed diagnostic laboratories in North America. Topics cover the perceived adequacy of current pre-fellowship training, as well as new modalities for professional development. Scored results and free-text comments, when desired by the respondent, will be summarized on the site. In addition to gauging current sentiments, we hope to connect professionals across institutions/subdisciplines and share ideas for curricular development. Given the central role of laboratory medicine in modern healthcare, a robust and equitable pipeline for developing future leaders will benefit both the field itself and the vast number of patients that it serves.

Author Contributions

All authors confirmed they have contributed to the intellectual content of this paper and have met the following 4 requirements: (a) significant contributions to the conception and design, acquisition of data, or analysis and interpretation of data; (b) drafting or revising the article for intellectual content; (c) final approval of the published article; and (d) agreement to be accountable for all aspects of the article thus ensuring that questions related to the accuracy or integrity of any part of the article are appropriately investigated and resolved.

Authors’ Disclosures or Potential Conflicts of Interest

No authors declared any potential conflicts of interest.

Acknowledgment

In addition to the NIH BEST award (cited above), these training opportunities for graduate students in Laboratory Medicine were supported by the Vanderbilt Department of Pathology, Microbiology, and Immunology and the Vanderbilt Trans-Institutional Program.

ABBREVIATIONS

ABBREVIATIONS
 
• ACGME

  Accreditation Council for Graduate Medical Education

 
• VUMC

  Vanderbilt University Medical Center

 
• BEST

  Broadening Experiences in Scientific Training

Author notes

Jennifer M. Colby and Ferrin C. Wheeler individuals contributed equally to this work.